General Surgery Coding Alert

Don't let inappropriate bundles cost you $500 or more

You have to consider many factors when reporting colonoscopies -- the various types of scopes, surgical techniques, instruments and locations, and, of course, how to avoid bundling -- but by remembering three helpful hints you can easily navigate this coding maze.

1. Answer 3 Questions: What? Where? How?

First, you must read the physician's dictation and verify that he performed a colonoscopy, says Sherri Brasher, insurance and billing specialist at a physician practice in Indiana.

If the physician performs polypectomy: Find out how she removed the polyp (biopsy or snare). In the case of multiple polyp removal, determine where on the colon each polyp was located and whether they were in separate locations or close enough to be considered one location. Next, you should check the method by which the surgeon removed each polyp, Brasher says.

To help you through ambiguous chart documentation, remember these code/procedure descriptions:

CPT 45380 -- Cold Biopsy Forceps. These are disposable forceps that take tissue samples during an endoscopy. No electric current passes through them - thus, the term "cold." You cannot use these forceps to cauterize bleeding that the forceps may cause. A partial polypectomy is usually a cold biopsy, Brasher says, whereas a total or entire procedure is done with a snare (45385), which lassoes the polyp.

45381 -- With Directed Submucosal Injections. This relatively new code, 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance), became effective on Jan. 1, 2003. The "substance" could include saline, India ink, methylene blue, Botox or steroids. Because the code is still new, be sure to verify coverage with your carrier, says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.

45382 -- Control of Bleeding. No, it's not a trick: Surgeons may use many of the same techniques for cauterization (to control bleeding) and for ablation - and the code definition can also be confusing. But the defining factor is the diagnosis. For example, use 45382 when controlling bleeding from a polyp removed several days ago or for diverticulosis 562.12 (Diverticulosis of colon with hemorrhage) or 562.13 (Diverticulitis of colon with hemorrhage). Another application, Brasher says, is for angiodysplasia 569.85 (Angiodysplasia of intestine with hemorrhage).

Note: You cannot separately bill 45382 if the surgeon has caused the bleeding during the colonoscopy.

45383 -- Ablation. An ablation, normally performed during a follow-up colonoscopy, usually refers to a cauterization performed with an argon plasma coagulator (APC), heater probe, or other device that destroys any remaining polyp cells after a prior colonoscopy in which the surgeon removed a larger polyp using a snare.

When using any of these methods either for an ablation or to control bleeding, use 45383 (Colonoscopy ...; with ablation of tumor[s], polyp[s], or other lesions[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Be careful: You shouldn't apply 45383 when the doctor uses hot biopsy forceps, bipolar cautery or snare technique for the ablation.

45384 -- Hot Biopsy Forceps or Bipolar Cautery. When the surgeon both removes and cauterizes a polyp simultaneously using hot biopsy forceps, you should use
45384 (Colonoscopy ...; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). Normally, these are smaller polyps. Also apply this code for bipolar cautery.

45385 -- Snare Technique. Usually, surgeons remove polyps -- especially larger ones -- during a colonoscopy with the snare technique, which employs an electrocautery snare (a heated wire loop that shaves off the polyp). In this situation, use 45385 (Colonoscopy ...; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). Physicians could theoretically also use these snares, also called "hot snares," for cautery, but that's unusual. A snare has cautery on it, but you're not ablating the polyp, Brasher says.

If two polyps are located right next to each other -- a small one right beside a large one -- and the physician spends a lot of time trying to remove the smaller polyp after removing the larger one, you should append modifier -22 (Unusual procedural services) so the physician is compensated and reimbursed for her time, Brasher says.

2. Adhere to Bundling and Modifier Policies

If you're going to bill 45384 or 45385, remember that the National Correct Coding Initiative bundles 45380 into both of them.

Under certain circumstances, however, you can code both the biopsy and the polypectomy if you append modifier -59 (Distinct procedural service) to the lesser-valued code. By overcoming the edit in these cases, you can legitimately increase your reimbursement by as much as $500 (the value of 45380).

Example 1: If the physician performs a biopsy at one site (45380) and removes a polyp at another site with a cold snare technique (45385), you would list 45385 first and append modifier -59 to 45380.

Example 2: The surgeon takes a biopsy at one site (45380) and removes a polyp at another site with hot biopsy forceps (45384). In this case, report 45384 first, followed by 45380 with modifier -59 appended. The -59 modifier indicates to the payer that the surgeon performed the procedures at different locations.

3. Follow Billing-Frequency Rules

To avoid denials, make sure you bill 45380 only once during a colonoscopy -- regardless of how many biopsies the surgeon performs. This applies even if the surgeon takes biopsies at several different locations (for instance, the transverse and descending colon).

You can also bill 45381 only once per session, even though the physician may administer multiple injections during the procedure.

Likewise, no matter how many tumors, polyps or lesions the doctor treats by the same or similar techniques, remember that the words "tumor(s), polyp(s), or other lesion(s)" in the descriptions of 45383, 45384 and 45385 signal that you're also restricted to reporting only one of these codes per colonoscopy.

When the surgeon uses different techniques, though, you can bill multiple tumor, polyp or lesion removals, as long as you report each code only once per technique.

Example: The surgeon uses hot biopsy forceps and the snare technique to remove polyps during a single colonoscopy. In this case, you should report both 45384 and 45385. The payer should reimburse for both procedures (although you may face a multiple-procedure fee reduction for the second and any subsequent codes).